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A 21-year-old woman with a history of rheumatic fever at 7 years of age presented with left-sided weakness. A large ischemic infarction involving the territory of the right middle cerebral artery was diagnosed. Cardiac evaluation revealed atrial fibrillation. Echocardiography showed normal aortic, pulmonic, and tricuspid valves, severe mitral stenosis with a valve area of 0.9 cm2, and a large free-floating ball-valve thrombus in the dilated (to 5 cm in diameter) left atrium (Panels A and B, arrows), which partially obstructed the mitral valve intermittently (Panels C and D, arrows, and video). After initial stabilization, the patient was treated with digoxin, warfarin, and penicillin G benzathine at a dose of 1.2 million units every 21 days. After 6 months of physical therapy, she underwent an open mitral valvotomy with removal of the ball-valve thrombus and an increase in the mitral-valve area to 2.8 cm2. Rheumatic heart disease remains a major health issue in India, with one recent study estimating the prevalence as 6.8 cases per 10,000 schoolchildren. Our patient is doing well after surgery, with minimal residual left hemiparesis and facial weakness.
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